MEDICARE: SAMANTHA KISSIG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101Y00000X	Counselor
2	1041C0700X	Clinical Social Worker	I.2102575-SUPV	OH

General Provider Information

NPI Number	:	1558710087
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA KISSIG

Provider Business Mailing Address
First Line	:	34950 CHARDON RD STE 210
Second Line	:
City	:	WILLOUGHBY HILLS
State	:	OH
Zip	:	44094-9162
Country	:	US
Telephone Number	:	440-596-9862
Fax Number	:

Provider Business Practice Location Address
First Line	:	34950 CHARDON RD STE 210
Second Line	:
City	:	WILLOUGHBY HILLS
State	:	OH
Zip	:	44094-9162
Country	:	US
Telephone Number	:	216-505-9536
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/06/2016
Last Update Date	:	01/12/2026

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Directions to “ SAMANTHA KISSIG ” Practice Location

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